Prescribing system contributes to fatal medication error

A coroner has highlighted the fact that the design of a prescribing system may have contributed to the death of a patient.

A Doctor prescribed a prophylactic dose of Enoxaparin rather than an intended therapeutic dose which she had intended to prescribe.

The patient, unfortunately, subsequently collapsed and suffered a cardiac arrest. Twenty-seven cycles of CPR were commenced and thrombolysis was given on the 11th cycle.

Sadly, the patient could not be revived and he died.


The patient was admitted to the hospital on 14th June 2021 with suspected DVT and PE. He arrived at the hospital at 13.28, however was not clerked by a Doctor until 21.33. The reason given for this was that the department was highly pressured on this date, and although a Junior Doctor had assigned the case to them by “clicking”, that Doctor had not in fact been able to see Mr Collinson. He did not “unclick” the patient and therefore other Doctors who may have had capacity were not aware that Mr Collinson had not been seen.

The reason for the error was that the electronic prescribing system is a drop-down box with confusing tables to select the medication. The Doctor was under pressure due to the busy department and accepted this was a human error, having accidentally selected the wrong one.

The Coroner was also told that no secondary check “pops up” requiring the Doctor to check the selection and confirm that is the prescription that was intended.

The medical cause of death was determined to be a pulmonary embolism and deep vein thrombosis.

Commenting on the case the Coroner said:

“During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken.

“The current system for allocating patients requires a manual check to see whether a patient has actually been seen once they have been allocated. If they are not seen, there is currently no way of other clinicians being aware of that, and therefore patients could be left for long periods of time without having been assessed.

“The current electronic prescribing system does not require a Doctor to perform a secondary check that they have selected the correct medication. I am concerned that it is all too easy to select the wrong medication, particularly when the department is busy and Doctors are under pressure. This could lead to fatal outcomes for patients if given incorrect medication.”

Elements of this story have been shared under the open government license.

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